Physician, Health Care Professional, Facility and Ancillary Provider Administrative Guide for American Medical Security Life Insurance Company

Transcription

1 Physician, Health Care Professional, Facility and Ancillary Provider Administrative Guide for American Medical Security Life Insurance Company Insureds 2009

2 Contents How to contact us... 2 Our claims process... 3 Complete claims... 4 Insured identification card... 8 Notification requirements... 9 Administrative Guide for American Medical Security Life Insurance Company Insureds 2009

3 How to contact us Notification Call the number on the back of the insured s ID card or , ext To notify of hospitalizations exceeding 3 days or transplant services outlined in the notification requirements section of this guide. Benefits and Eligibility Call the number on the back of the insured s ID card or , ext To inquire about an insured s plan benefits or eligibility. Pharmacy Services (Prescription Solutions) Call the number on the back of the insured s ID card or To request a copy of the Prescription Drug List Administrative Guide for American Medical Security Life Insurance Company Insureds

4 Our claims process We know that you want to be paid promptly for the services you provide. Here s what you can do to help promote prompt payment: 1. Notify us on or before the 4th day of hospitalizations that are expected to exceed three days. 2. Notify us as soon as possible of proposed transplant procedures. 3. Prepare a complete and accurate claim form (see Complete claims on page 4.) 4. For American Medical Security Life Insurance Company insureds Submit electronic claims using Payor ID # This is the electronic claims routing number for American Medical Security Life Insurance Company insureds. 5. For American Medical Security Life Insurance Company insureds Submit paper claims to the address on the insured s ID card. 3 Administrative Guide for American Medical Security Life Insurance Company Insureds 2009

5 Complete claims Whether you use an electronic or paper form, complete a CMS-1500 or UB-04 form. A complete claim includes the following information. Additional information may be required by us for particular types of services or based on particular circumstances or state requirements. Patient s name, address, sex, date of birth Primary insured s name and ID number Name, signature, remit to address and phone number of physician or health care provider performing the service, as in your contract document Physician s or health care provider s National Provider Identifier (NPI) and federal tax ID number Date of service(s), place of service(s) and number of services (units) rendered Current CPT-4 and HCPCS procedure codes with modifiers where appropriate Current ICD-9 diagnostic codes by specific service code to the highest level of specificity Referring physician s name and tax ID number (if applicable) Charges per service and total charges Information about other insurance coverage, including job-related, auto or accident information, if available Attach operative notes for claims submitted with modifiers 22, 62, 66 or any other team surgery modifiers as well as CPT (physician standby) Attach an anesthesia report for claims submitted with a 23, QS, G8 or G9 modifier Attach nursing notes and treatment plan for claims submitted for home health care, nursing or skilled nursing services Purchase price for DME rental claims exceeding $500 Medical records for growth hormone, co-surgeries, dental care resulting from an accident or injury to the teeth, maternity (except routine) For bone marrow/stem cell or organ transplant claims: transplant evaluation and transplant treatment protocols For reconstructive and/or cosmetic procedures regarding the cranio-facial region, breast, nose, eyes or abdomen: treatment plan, medical records for the last 2 years regarding the condition, operative notes For experimental and/or investigational treatments (including Phase I or II clinical trials): consent forms signed by the patient, medical records for the last 2 years regarding the condition, admission and discharge summaries, treatment protocols For medical claims involving self-inflicted injuries or illnesses: admission and discharge summaries and progress notes during the confinement For HIV-related diseases and AIDS: onset information (first date diagnosed) and admission and discharge summaries for inpatient claims For accident and injury claims: summary of accident and injury (including date, place, and circumstances) Electronic claims must be HIPAA-compliant in order to be considered clean claims, using the applicable format that complies with all federal laws related to electronic health care claims, including any applicable implementation guides, companion guides, and trading partner agreements Administrative Guide for American Medical Security Life Insurance Company Insureds

6 Additional information needed for a complete UB-04 form: Date and hour of admission and discharge as well as insured status-at-discharge code Type of bill code Type of admission (e.g. emergency, urgent, elective, newborn) Current four-digit revenue code(s) Current principal diagnosis code (highest level of specificity) with the applicable Present of Admission (POA) indicator on hospital inpatient claims per CMS guidelines Current other diagnosis codes, if applicable (highest level of specificity), with the applicable Present on Admission (POA) indicator on hospital inpatient claims per CMS guidelines Current ICD-9-CM procedure codes for inpatient procedures Attending physician ID Bill all outpatient surgeries with the appropriate revenue and CPT or HCPCS codes Provide specific CPT or HCPCS codes and appropriate revenue code(s) (e.g. laboratory, radiology, diagnostic or therapeutic) for outpatient services Complete box 45 for physical, occupational or speech therapy services (revenue code ) submitted on a UB- 04 Attach an itemized statement if submitting a claim that will reach the contracted stop loss Submit claims according to any special billing instructions that may be indicated in your agreement (or letter of agreement) On an inpatient hospital bill type of 11x, the admission date and time should always reflect the actual time the member was admitted to inpatient status If charges are rolled to the first surgery revenue code line on hospital outpatient surgery claims, a nominal monetary amount ($.01 or $1.00) must be reported on all other surgical revenue code lines to assure appropriate adjudication Claim correction/resubmit If you need to correct and resubmit a claim, submit a new CMS-1500 or UB-04 indicating the correction being made. When correcting or submitting late charges on a UB-04 or 837 Institutional claim, resubmit all original lines and charges as well as the corrected or additional information using bill type xx7, Replacement of Prior Claim. Do not submit corrected or additional charges using bill type xx5, Late Charge Claim. Hand-corrected resubmissions will not be accepted. Submission of unlisted medical surgical codes Include a detailed description of the procedure or service provided for claims submitted with unlisted medical or surgical CPT or other revenue codes as well as experimental or reconstructive services. Submission of CMS-1500 form drug codes Include current NDC (National Drug Code) 11-digit number for all claims submitted with drug codes. The NDC number must be entered in the 24D field of the CMS-1500 form or the LINo3 segment of the HIPAA 837 electronic form. If you have questions about submitting claims to us, please contact American Medical Security Life Insurance Company at the phone number listed on the insured s ID card. 5 Administrative Guide for American Medical Security Life Insurance Company Insureds 2009

7 Reporting requirements for anesthesia services One of the CMS required modifiers (AA, AD, QK, QX, QY, QZ, G8, G9 or QS) must be used for anesthesia services reporting For electronic claims, report the actual number of anesthesia minutes in loop 2400 SV104 with a MJ qualifier in loop 2400 SV103. For CMS-1500 paper claims, report the actual number of minutes in Box 24G with qualifier MJ in Box 24H When medically directing residents for anesthesia services, the modifier GC must be reported in conjunction with the AA or QK modifier When reporting obstetrical anesthesia minutes, use add-on codes or 01969, as applicable, on the same claim as the primary procedure When using qualifying circumstance codes 99100, 99116, and/or 99140, report the qualifier on the same claim with the anesthesia service National Provider Identification (NPI) UnitedHealthcare and its affiliates are able to accept the National Provider Identifier (NPI) on all HIPAA transactions, including the 837 professional and institutional (paper and electronic) claims submissions. A valid NPI is required on all covered claims (paper and electronic) in addition to the tax identification number (TIN). For institutional claims, please include the billing provider National Uniform Claim Committee (NUCC) taxonomy. Since May 23, 2008, Medicare and many state Medicaid agencies require the use of your NPI on all electronic and paper claim submissions. You must include a valid NPI on all Medicare and Medicaid claims submitted for payment. Any changes to our NPI policy will be preceded by communications to physicians, health care professionals, organizations and trading partners. Such communications will indicate when we will reserve the right to no longer accept HIPAA transactions that do not contain a valid NPI. If you have not yet applied for and received your NPI, please do so immediately by visiting UnitedHealthcare will continue to accept NPIs submitted through any of the following methods: 1. UnitedHealthcare Online (UnitedHealthcareOnline.com) To update your NPI and related information online: UnitedHealthcareOnline.com Practice/Facility Profile Log in with your User Identification and Password (your tax identification number will allow you to access these screens online) Continue View/Update NPI Information tab 2. For all UnitedHealthcare business, fax your NPI to the appropriate fax number based on your geographic location/ state. The fax form can be found under Most Visited and National Provider Identifier at UnitedHealthcareOnline.com 3. Call (877) , the United Voice Portal. Select the Health Care Professional Services prompt. State demographic changes and your call will be directed to the Service Center to collect your NPI, corresponding NUCC Taxonomy Codes, and other NPI-related information. 4. NPI and NUCC taxonomy indicator(s) are collected as part of credentialing, recredentialing, new provider contracting and recontracting efforts. Administrative Guide for American Medical Security Life Insurance Company Insureds

8 Claim adjustments If you believe you were underpaid, please call American Medical Security Life Insurance Company at (800) and request an adjustment as soon as possible and in accordance with applicable statutes and regulations. If you or our staff identify a claim were you were overpaid, we ask that you send us the overpayment within 30 calendar days from the date of your identification of the overpayment or of our request. American Medical Security Life Insurance Company typically makes claim adjustments without requesting additional information from the network physician or other health care professional. You will see the adjustment on the Explanation of Benefits (EOB). When additional or correct information is needed, American Medical Security Life Insurance Company will ask you to provide it. If you disagree with a claim adjustment, you can appeal the determination (see Claims appeals). Subrogation and Coordination of Benefits Our benefits contracts are subject to subrogation, coordination of benefits (COB) rules, or similar provisions. We reserve the legal right to recover benefits paid for an insured s health care services when a third party causes the insured s injury or illness. Coordination of benefits is administered according to the insured s benefit contract and in accordance with applicable statutes and regulations. Claims appeals If you disagree with a claim payment determination, send a letter of appeal to: American Medical Security Life Insurance Company Appeals Review, P.O. Box 13597, Green Bay, WI Your appeal must be submitted to American Medical Security Life Insurance Company within 180 days from the date of payment shown on the EOB, unless your agreement or applicable law provide otherwise. If you are appealing a claim that was denied because filing was not timely, for: 1. Electronic claims include confirmation that American Medical Security Life Insurance Company received and accepted your claim. 2. Paper claims include a copy of a screen print from your accounting software to show the date you submitted the claim. If you disagree with the outcome of the claim appeal, an arbitration proceeding may be filed as described in our agreement. Retroactive eligibility changes Eligibility under a benefit contract may change retroactively. If you have submitted a claim(s) that is impacted by a retroactive eligibility change, a claim adjustment may be necessary. The reason for the claim adjustment will be reflected on the EOB. 7 Administrative Guide for American Medical Security Life Insurance Company Insureds 2009

9 Insured s identification card American Medical Security Life Insurance Company insureds receive an ID card containing information that helps you submit claims accurately and completely. Information will vary in appearance or location on the card. However, cards display essentially the same information (e.g., claims address, copayment information, telephone numbers). Be sure to check the insured s ID card at each visit and to copy both sides of the card for your files. Also, be sure to use American Medical Security Life Insurance Company electronic Payor ID # when filing electronic claims. ID Card Sample ID card showing the type of information displayed. Administrative Guide for American Medical Security Life Insurance Company Insureds

10 Notification requirements Notification, in order to be effective, must contain all necessary information, including but not limited to insured s name, insured s ID, hospital name, hospital tax identification number, ICD-9 code for primary diagnosis (maximum 2 additional diagnoses), anticipated dates of service, type of service and volume of service when applicable. In addition, such notifications must be made to the appropriate place as described on the insured s ID card. Notify American Medical Security at the number listed on the insured s ID card for any inpatient facility admission that will exceed 3 days and for proposed transplant services. Notify us prior to: Procedures and services Explanation Inpatient facility admissions Inpatient admissions expected to exceed three days including: acute hospitalizations (includes long term acute care), rehabilitation facilities, and skilled nursing facilities (includes subacute and hospice) that will exceed 3 days. Notify on or before 4th inpatient day. Transplant services Proposed transplant services including evaluations. American Medical Security Life Insurance Company uses Milliman Care Guidelines, which are nationally recognized clinical guidelines, to assist clinicians in making informed decisions in many health care settings, including acute and subacute medical, rehabilitation, skilled nursing facilities, home health care and ambulatory facilities. As an affiliate of UnitedHealthcare, American Medical Security Life Insurance Company may also utilize the medical policies available online at UnitedHealthcareOnline.com Tools & Resources Policies and Protocols. Notification does not guarantee coverage or payment (unless mandated by the state). The insured s eligibility for coverage is determined by the health benefit plan. For benefit or coverage information, please contact American Medical Security Life Insurance Company at the number on the back of the insured s ID card. 9 Administrative Guide for American Medical Security Life Insurance Company Insureds 2009

11 Notes Administrative Guide for American Medical Security Life Insurance Company Insureds

12 M / United HealthCare Services, Inc.